Urinary incontinence affects approximately 50% of women, with up to 80% of these women experiencing stress urinary incontinence (SUI) at some point in their lives.^1-3 While conservative measures can offer some improvement in symptoms, the mainstay of treatment for SUI is surgical intervention.^4,5 The lifetime risk of undergoing surgery for SUI is 13.6%, and surgery leads to a major improvement in quality of life and productivity.^1,6

Types of slings used for SUI

Sling procedures are the most commonly used surgical approach for the treatment of SUI. Two types of urethral slings are used: the midurethral sling and the autologous fascial (pubovaginal) sling. The midurethral sling, which is the most frequently used sling today, can be further characterized as the retropubic sling, the transobturator sling, and the mini sling (FIGURE 1).

Retropubic sling

A retropubic sling is a midurethral mesh sling that is placed beneath the urethra at the midpoint between the urethral meatus and the bladder neck. The arms of the sling extend behind the pubic symphysis, providing a hammock-like support that helps prevent leakage with increased abdominal pressures. The retropubic sling is the most commonly used type of sling. For women presenting with uncomplicated SUI who desire surgical correction, it often is the best choice for providing long-term treatment success.⁷

Transobturator sling

A transobturator sling is a midurethral mesh sling that is placed beneath the urethra as described above, but the arms of the sling extend outward through the obturator foramen and into the groin. This enables support of the midurethra, but this sling is less likely to result in such complications as bladder perforation or postoperative urinary retention. Transobturator slings also are associated with lower rates of voiding dysfunction and urinary urgency than retropubic slings.^7-9 However, transobturator slings have higher rates of groin pain, and they are less effective in maintaining long-term cure of SUI.⁷

First introduced in 1996, the midurethral sling quickly grew in popularity for the treatment of SUI because of its high success rates and its minimally invasive approach.¹⁰ Both retropubic and transobturator slings are safe, extensively researched surgical approaches for the management of SUI.³ Midurethral slings have a very high rate of incontinence cure (80%–90%) and extremely high patient satisfaction rates (85%–90%), as even patients without complete cure report meaningful symptomatic improvement.^7,8,11

Single-incision (mini) sling

A single-incision sling is a midurethral mesh sling that is designed to be shorter in length than standard midurethral slings. The placed sling lies under the midurethra and extends toward the superior edge of the obturator foramen but does not penetrate it. The sling is held in place by small pledgets on either side of the mesh hammock that anchor it in place to the obturator internus muscular fascia. Because this “mini” sling was introduced in 2006, fewer long-term data are available for this sling than for standard midurethral slings.

Continue to: Autologous (fascial) sling...

Autologous (fascial) sling

An autologous sling is a retropubic sling made from the patient’s own fascia; it is harvested from either the fascia lata of the lateral thigh or the rectus fascia of the abdomen. The sling is placed beneath the urethra in the bladder neck region, and sutures affixed to the sling edges pass behind the pubic symphysis and through the abdominal fascia to anchor it in place.

Choose a sling based on the clinical situation and patient goals

Consider the unique features of each sling when selecting the proper sling; this should be a shared decision with the patient after thorough counseling. Below, we present 4 clinical cases to exemplify scenarios in which different slings are appropriate, and we review the rationale for each selection.

CASE 1 SUI that interferes with exercise routine

Ms. P. is a 46-year-old (G3P3) active mother. She loves to exercise, but she has been working out less frequently because of embarrassing urinary leakage that occurs with activity. She has tried pelvic floor exercises and changing her fluid intake habits, but improvements have been minimal with these interventions. On evaluation, she has a positive cough stress test with a recently emptied bladder and a normal postvoid residual volume.

What type of sling would be best?

Because this patient is young, active, and has significant leakage with an empty bladder, a sling with good long-term treatment success is likely to provide her with the best results (Figure 1). We therefore offered her a retropubic midurethral sling. The retropubic approach is preferred here as it is less likely than the transobturator sling to cause groin/thigh pain, which is an important consideration in this young, active patient.

Further testing is not needed

For women with uncomplicated SUI who demonstrate leakage with stress (coughing, Valsalva stress test) and who have a normal postvoid residual volume, additional testing, such as urodynamic evaluation, is not necessary.¹² These patients can be counseled on the range of conservative management options and as well as surgical inventions.

CASE 2 Return of SUI symptoms after transobturator sling placement

Ms. E. is a 70-year-old woman who had a transobturator sling placed 5 years ago. Initially, her SUI symptoms improved after surgery. Recently, however, she noticed a return of her SUI, which she finds bothersome and limiting to her quality of life.

How would you manage this patient?

While midurethral slings are highly effective, there are instances in which patients will have symptom recurrence. For women who already have a midurethral sling, consider the following important questions.

Is this truly recurrent SUI, or is it a new process?

Like any reconstructive procedure, midurethral sling success rates decline over time and recurrent SUI can develop.⁷ However, it also is possible for urge urinary incontinence to develop as a new process, and it is important to distinguish which type of urinary incontinence your patient has prior to counseling about treatment options.

To further evaluate patients with recurrent incontinence and a prior sling, we recommend urodynamic studies with cystoscopy (in addition to a detailed history and physical exam). This not only helps rule out other forms of incontinence, such as overactive bladder, but also evaluates for possible mesh erosion into the urethra or bladder, which can cause irritative voiding symptoms and incontinence.

Continue to: What type of sling did the patient have initially...

What type of sling did the patient have initially, and how does this impact a repeat procedure?

Regardless of the initial sling type used, repeat midurethral sling procedures have a significantly lower cure rate than primary midurethral sling procedures.¹³ Retropubic slings are more effective than transobturator slings for patients with recurrent SUI who have failed a prior sling. When a patient presents with recurrent SUI after a prior transobturator sling, the best option for a repeat procedure is usually a retropubic sling, as it achieves higher objective and subjective cure rates.^13,14 (See FIGURE 2 for a comparison of retropubic and transobturator slings.)


Should I remove the old sling prior to placing a new one?

While it is recommended to remove the vaginal portion of the sling if the patient has a mesh exposure or is experiencing other symptoms, such as pain or bleeding, removal of the old sling is not necessarily indicated prior to (or during) a repeat incontinence procedure.^15,16 Removing the sling, removing a portion of the sling, or leaving the sling in situ are all reasonable options.

CASE 3 Treated SUI has mesh exposure

Ms. R. is a 60-year-old woman with a history of SUI that was previously managed with a retropubic midurethral sling placed at an outside hospital. She is a smoker and has developed a vaginal mesh exposure. Although she would like the mesh removed, she does not want her incontinence to come back. She tells you that she does not think she would be able to quit smoking.

What would be a reasonable next option for Ms. R.?

While complications from a midurethral sling are rare, mesh exposures occur in approximately 2% of patients, and urinary retention requiring release of the sling occurs in about 1% of patients.^3,6 It often helps to clarify for patients that the US Food and Drug Administration public health advisories on the use of transvaginal mesh have been directed specifically toward the use of transvaginal mesh for the treatment of pelvic organ prolapse (POP), not the use of mesh for midurethral slings for SUI or transabdominal mesh for POP.^10,17

When considering use of a mesh sling, a thorough discussion of the potential risks, as well as the benefits and alternatives, is imperative. Patients must personally balance the probability of benefit with the potential risk of complications, and while physicians can help outline the benefits and risks through shared decision-making, ultimately it is the patient who should make this decision.

Certain patient populations may be at higher risk for mesh complications¹⁸ (See "Risk factors for mesh-related complications," below). These complications are managed in various ways (FIGURE 3). Patients who have experienced mesh complications previously are typically not good candidates for a repeat mesh sling, particularly when the risk factor for complications cannot be modified.

A mesh sling alternative

The most effective way to manage SUI in patients who are not good candidates for a mesh sling is to consider employing a sling that uses the patient’s own tissue.^19-21 Common approaches include harvesting a graft of rectus fascia through a Pfannenstiel skin incision or using fascia lata from the patient’s iliotibial band in the lateral thigh. Autologous slings are safe and effective, and even after a mesh sling has failed, autologous slings have an almost 70% cure rate for SUI.^20,21

Continue to: Timing of mesh removal and placement of an autologous fascial sling...

Timing of mesh removal and placement of an autologous fascial sling

Either concomitant or delayed placement of a pubovaginal sling is acceptable when removing mesh, though this should be a joint decision with the patient after counseling. If the risk for surgical complications is modifiable (for example, poorly controlled diabetes that could be improved with blood glucose control), it may be advisable to delay the fascial sling until the risk factors have been addressed. Similarly, if the reason for mesh removal is pain, it may be advisable to remove the mesh prior to placing a new sling to ensure that the pain resolves completely. Otherwise, if pain persists, it can be unclear whether the new sling is contributing to the pain, and this may lead to difficulties treating pain or incontinence in the future.

In this patient, who was an active smoker, we excised the exposed mesh and concomitantly placed an autologous fascial sling utilizing rectus fascia. This maintained continence without introducing mesh in a high-risk patient.

CASE 4 POP and occult SUI

Ms. B. is a 79-year-old woman with stage 3 POP planned for surgical repair. While she does not report urinary leakage, preoperative urodynamic testing revealed occult SUI with reduction of her prolapse. Her priorities are to avoid needing another surgery and to limit the chances of postoperative leakage, but she is nervous about her postoperative recovery and wants to avoid pain.

What approach would be appropriate?

Consider a mini sling for this patient

The single-incision (mini) sling is an option to consider for patients with mild incontinence or for those without evidence of intrinsic sphincter deficiency. It is also a good option for those who want to avoid the additional incisions required for full-length slings.

While currently there is not sufficient evidence to clearly state if single-incision slings are equivalent to other slings, recent studies show that single-incision slings appear to be safe and effective in the short term, with possibly fewer complications than traditional transobturator slings.^22-24 As patients are often concerned about the potential for groin pain with a transobturator sling, a single-incision sling is an acceptable alternative that avoids groin incisions and also avoids the retropubic space.

Patient counseling is crucial

Regardless of the route, sling procedures are highly effective and safe for treating women with SUI.³ Understanding the characteristics of each type of sling and the distinct surgical approaches enables informed counseling for patients who are navigating the treatment options for SUI.

Urinary incontinence affects approximately 50% of women, with up to 80% of these women experiencing stress urinary incontinence (SUI) at some point in their lives.^1-3 While conservative measures can offer some improvement in symptoms, the mainstay of treatment for SUI is surgical intervention.^4,5 The lifetime risk of undergoing surgery for SUI is 13.6%, and surgery leads to a major improvement in quality of life and productivity.^1,6

Types of slings used for SUI

Sling procedures are the most commonly used surgical approach for the treatment of SUI. Two types of urethral slings are used: the midurethral sling and the autologous fascial (pubovaginal) sling. The midurethral sling, which is the most frequently used sling today, can be further characterized as the retropubic sling, the transobturator sling, and the mini sling (FIGURE 1).

Retropubic sling

A retropubic sling is a midurethral mesh sling that is placed beneath the urethra at the midpoint between the urethral meatus and the bladder neck. The arms of the sling extend behind the pubic symphysis, providing a hammock-like support that helps prevent leakage with increased abdominal pressures. The retropubic sling is the most commonly used type of sling. For women presenting with uncomplicated SUI who desire surgical correction, it often is the best choice for providing long-term treatment success.⁷

Transobturator sling

A transobturator sling is a midurethral mesh sling that is placed beneath the urethra as described above, but the arms of the sling extend outward through the obturator foramen and into the groin. This enables support of the midurethra, but this sling is less likely to result in such complications as bladder perforation or postoperative urinary retention. Transobturator slings also are associated with lower rates of voiding dysfunction and urinary urgency than retropubic slings.^7-9 However, transobturator slings have higher rates of groin pain, and they are less effective in maintaining long-term cure of SUI.⁷

First introduced in 1996, the midurethral sling quickly grew in popularity for the treatment of SUI because of its high success rates and its minimally invasive approach.¹⁰ Both retropubic and transobturator slings are safe, extensively researched surgical approaches for the management of SUI.³ Midurethral slings have a very high rate of incontinence cure (80%–90%) and extremely high patient satisfaction rates (85%–90%), as even patients without complete cure report meaningful symptomatic improvement.^7,8,11

Single-incision (mini) sling

A single-incision sling is a midurethral mesh sling that is designed to be shorter in length than standard midurethral slings. The placed sling lies under the midurethra and extends toward the superior edge of the obturator foramen but does not penetrate it. The sling is held in place by small pledgets on either side of the mesh hammock that anchor it in place to the obturator internus muscular fascia. Because this “mini” sling was introduced in 2006, fewer long-term data are available for this sling than for standard midurethral slings.

Continue to: Autologous (fascial) sling...

Autologous (fascial) sling

An autologous sling is a retropubic sling made from the patient’s own fascia; it is harvested from either the fascia lata of the lateral thigh or the rectus fascia of the abdomen. The sling is placed beneath the urethra in the bladder neck region, and sutures affixed to the sling edges pass behind the pubic symphysis and through the abdominal fascia to anchor it in place.

Choose a sling based on the clinical situation and patient goals

Consider the unique features of each sling when selecting the proper sling; this should be a shared decision with the patient after thorough counseling. Below, we present 4 clinical cases to exemplify scenarios in which different slings are appropriate, and we review the rationale for each selection.

CASE 1 SUI that interferes with exercise routine

Ms. P. is a 46-year-old (G3P3) active mother. She loves to exercise, but she has been working out less frequently because of embarrassing urinary leakage that occurs with activity. She has tried pelvic floor exercises and changing her fluid intake habits, but improvements have been minimal with these interventions. On evaluation, she has a positive cough stress test with a recently emptied bladder and a normal postvoid residual volume.

What type of sling would be best?

Because this patient is young, active, and has significant leakage with an empty bladder, a sling with good long-term treatment success is likely to provide her with the best results (Figure 1). We therefore offered her a retropubic midurethral sling. The retropubic approach is preferred here as it is less likely than the transobturator sling to cause groin/thigh pain, which is an important consideration in this young, active patient.

Further testing is not needed

For women with uncomplicated SUI who demonstrate leakage with stress (coughing, Valsalva stress test) and who have a normal postvoid residual volume, additional testing, such as urodynamic evaluation, is not necessary.¹² These patients can be counseled on the range of conservative management options and as well as surgical inventions.

CASE 2 Return of SUI symptoms after transobturator sling placement

Ms. E. is a 70-year-old woman who had a transobturator sling placed 5 years ago. Initially, her SUI symptoms improved after surgery. Recently, however, she noticed a return of her SUI, which she finds bothersome and limiting to her quality of life.

How would you manage this patient?

While midurethral slings are highly effective, there are instances in which patients will have symptom recurrence. For women who already have a midurethral sling, consider the following important questions.

Is this truly recurrent SUI, or is it a new process?

Like any reconstructive procedure, midurethral sling success rates decline over time and recurrent SUI can develop.⁷ However, it also is possible for urge urinary incontinence to develop as a new process, and it is important to distinguish which type of urinary incontinence your patient has prior to counseling about treatment options.

To further evaluate patients with recurrent incontinence and a prior sling, we recommend urodynamic studies with cystoscopy (in addition to a detailed history and physical exam). This not only helps rule out other forms of incontinence, such as overactive bladder, but also evaluates for possible mesh erosion into the urethra or bladder, which can cause irritative voiding symptoms and incontinence.

Continue to: What type of sling did the patient have initially...

What type of sling did the patient have initially, and how does this impact a repeat procedure?

Regardless of the initial sling type used, repeat midurethral sling procedures have a significantly lower cure rate than primary midurethral sling procedures.¹³ Retropubic slings are more effective than transobturator slings for patients with recurrent SUI who have failed a prior sling. When a patient presents with recurrent SUI after a prior transobturator sling, the best option for a repeat procedure is usually a retropubic sling, as it achieves higher objective and subjective cure rates.^13,14 (See FIGURE 2 for a comparison of retropubic and transobturator slings.)


Should I remove the old sling prior to placing a new one?

While it is recommended to remove the vaginal portion of the sling if the patient has a mesh exposure or is experiencing other symptoms, such as pain or bleeding, removal of the old sling is not necessarily indicated prior to (or during) a repeat incontinence procedure.^15,16 Removing the sling, removing a portion of the sling, or leaving the sling in situ are all reasonable options.

CASE 3 Treated SUI has mesh exposure

Ms. R. is a 60-year-old woman with a history of SUI that was previously managed with a retropubic midurethral sling placed at an outside hospital. She is a smoker and has developed a vaginal mesh exposure. Although she would like the mesh removed, she does not want her incontinence to come back. She tells you that she does not think she would be able to quit smoking.

What would be a reasonable next option for Ms. R.?

While complications from a midurethral sling are rare, mesh exposures occur in approximately 2% of patients, and urinary retention requiring release of the sling occurs in about 1% of patients.^3,6 It often helps to clarify for patients that the US Food and Drug Administration public health advisories on the use of transvaginal mesh have been directed specifically toward the use of transvaginal mesh for the treatment of pelvic organ prolapse (POP), not the use of mesh for midurethral slings for SUI or transabdominal mesh for POP.^10,17

When considering use of a mesh sling, a thorough discussion of the potential risks, as well as the benefits and alternatives, is imperative. Patients must personally balance the probability of benefit with the potential risk of complications, and while physicians can help outline the benefits and risks through shared decision-making, ultimately it is the patient who should make this decision.

Certain patient populations may be at higher risk for mesh complications¹⁸ (See "Risk factors for mesh-related complications," below). These complications are managed in various ways (FIGURE 3). Patients who have experienced mesh complications previously are typically not good candidates for a repeat mesh sling, particularly when the risk factor for complications cannot be modified.

A mesh sling alternative

The most effective way to manage SUI in patients who are not good candidates for a mesh sling is to consider employing a sling that uses the patient’s own tissue.^19-21 Common approaches include harvesting a graft of rectus fascia through a Pfannenstiel skin incision or using fascia lata from the patient’s iliotibial band in the lateral thigh. Autologous slings are safe and effective, and even after a mesh sling has failed, autologous slings have an almost 70% cure rate for SUI.^20,21

Continue to: Timing of mesh removal and placement of an autologous fascial sling...

Timing of mesh removal and placement of an autologous fascial sling

Either concomitant or delayed placement of a pubovaginal sling is acceptable when removing mesh, though this should be a joint decision with the patient after counseling. If the risk for surgical complications is modifiable (for example, poorly controlled diabetes that could be improved with blood glucose control), it may be advisable to delay the fascial sling until the risk factors have been addressed. Similarly, if the reason for mesh removal is pain, it may be advisable to remove the mesh prior to placing a new sling to ensure that the pain resolves completely. Otherwise, if pain persists, it can be unclear whether the new sling is contributing to the pain, and this may lead to difficulties treating pain or incontinence in the future.

In this patient, who was an active smoker, we excised the exposed mesh and concomitantly placed an autologous fascial sling utilizing rectus fascia. This maintained continence without introducing mesh in a high-risk patient.

CASE 4 POP and occult SUI

Ms. B. is a 79-year-old woman with stage 3 POP planned for surgical repair. While she does not report urinary leakage, preoperative urodynamic testing revealed occult SUI with reduction of her prolapse. Her priorities are to avoid needing another surgery and to limit the chances of postoperative leakage, but she is nervous about her postoperative recovery and wants to avoid pain.

What approach would be appropriate?

Consider a mini sling for this patient

The single-incision (mini) sling is an option to consider for patients with mild incontinence or for those without evidence of intrinsic sphincter deficiency. It is also a good option for those who want to avoid the additional incisions required for full-length slings.

While currently there is not sufficient evidence to clearly state if single-incision slings are equivalent to other slings, recent studies show that single-incision slings appear to be safe and effective in the short term, with possibly fewer complications than traditional transobturator slings.^22-24 As patients are often concerned about the potential for groin pain with a transobturator sling, a single-incision sling is an acceptable alternative that avoids groin incisions and also avoids the retropubic space.

Patient counseling is crucial

Regardless of the route, sling procedures are highly effective and safe for treating women with SUI.³ Understanding the characteristics of each type of sling and the distinct surgical approaches enables informed counseling for patients who are navigating the treatment options for SUI.

Urinary incontinence affects approximately 50% of women, with up to 80% of these women experiencing stress urinary incontinence (SUI) at some point in their lives.^1-3 While conservative measures can offer some improvement in symptoms, the mainstay of treatment for SUI is surgical intervention.^4,5 The lifetime risk of undergoing surgery for SUI is 13.6%, and surgery leads to a major improvement in quality of life and productivity.^1,6

Types of slings used for SUI

Sling procedures are the most commonly used surgical approach for the treatment of SUI. Two types of urethral slings are used: the midurethral sling and the autologous fascial (pubovaginal) sling. The midurethral sling, which is the most frequently used sling today, can be further characterized as the retropubic sling, the transobturator sling, and the mini sling (FIGURE 1).

Retropubic sling

A retropubic sling is a midurethral mesh sling that is placed beneath the urethra at the midpoint between the urethral meatus and the bladder neck. The arms of the sling extend behind the pubic symphysis, providing a hammock-like support that helps prevent leakage with increased abdominal pressures. The retropubic sling is the most commonly used type of sling. For women presenting with uncomplicated SUI who desire surgical correction, it often is the best choice for providing long-term treatment success.⁷

Transobturator sling

A transobturator sling is a midurethral mesh sling that is placed beneath the urethra as described above, but the arms of the sling extend outward through the obturator foramen and into the groin. This enables support of the midurethra, but this sling is less likely to result in such complications as bladder perforation or postoperative urinary retention. Transobturator slings also are associated with lower rates of voiding dysfunction and urinary urgency than retropubic slings.^7-9 However, transobturator slings have higher rates of groin pain, and they are less effective in maintaining long-term cure of SUI.⁷

First introduced in 1996, the midurethral sling quickly grew in popularity for the treatment of SUI because of its high success rates and its minimally invasive approach.¹⁰ Both retropubic and transobturator slings are safe, extensively researched surgical approaches for the management of SUI.³ Midurethral slings have a very high rate of incontinence cure (80%–90%) and extremely high patient satisfaction rates (85%–90%), as even patients without complete cure report meaningful symptomatic improvement.^7,8,11

Single-incision (mini) sling

A single-incision sling is a midurethral mesh sling that is designed to be shorter in length than standard midurethral slings. The placed sling lies under the midurethra and extends toward the superior edge of the obturator foramen but does not penetrate it. The sling is held in place by small pledgets on either side of the mesh hammock that anchor it in place to the obturator internus muscular fascia. Because this “mini” sling was introduced in 2006, fewer long-term data are available for this sling than for standard midurethral slings.

Continue to: Autologous (fascial) sling...

Autologous (fascial) sling

An autologous sling is a retropubic sling made from the patient’s own fascia; it is harvested from either the fascia lata of the lateral thigh or the rectus fascia of the abdomen. The sling is placed beneath the urethra in the bladder neck region, and sutures affixed to the sling edges pass behind the pubic symphysis and through the abdominal fascia to anchor it in place.

Choose a sling based on the clinical situation and patient goals

Consider the unique features of each sling when selecting the proper sling; this should be a shared decision with the patient after thorough counseling. Below, we present 4 clinical cases to exemplify scenarios in which different slings are appropriate, and we review the rationale for each selection.

CASE 1 SUI that interferes with exercise routine

Ms. P. is a 46-year-old (G3P3) active mother. She loves to exercise, but she has been working out less frequently because of embarrassing urinary leakage that occurs with activity. She has tried pelvic floor exercises and changing her fluid intake habits, but improvements have been minimal with these interventions. On evaluation, she has a positive cough stress test with a recently emptied bladder and a normal postvoid residual volume.

What type of sling would be best?

Because this patient is young, active, and has significant leakage with an empty bladder, a sling with good long-term treatment success is likely to provide her with the best results (Figure 1). We therefore offered her a retropubic midurethral sling. The retropubic approach is preferred here as it is less likely than the transobturator sling to cause groin/thigh pain, which is an important consideration in this young, active patient.

Further testing is not needed

For women with uncomplicated SUI who demonstrate leakage with stress (coughing, Valsalva stress test) and who have a normal postvoid residual volume, additional testing, such as urodynamic evaluation, is not necessary.¹² These patients can be counseled on the range of conservative management options and as well as surgical inventions.

CASE 2 Return of SUI symptoms after transobturator sling placement

Ms. E. is a 70-year-old woman who had a transobturator sling placed 5 years ago. Initially, her SUI symptoms improved after surgery. Recently, however, she noticed a return of her SUI, which she finds bothersome and limiting to her quality of life.

How would you manage this patient?

While midurethral slings are highly effective, there are instances in which patients will have symptom recurrence. For women who already have a midurethral sling, consider the following important questions.

Is this truly recurrent SUI, or is it a new process?

Like any reconstructive procedure, midurethral sling success rates decline over time and recurrent SUI can develop.⁷ However, it also is possible for urge urinary incontinence to develop as a new process, and it is important to distinguish which type of urinary incontinence your patient has prior to counseling about treatment options.

To further evaluate patients with recurrent incontinence and a prior sling, we recommend urodynamic studies with cystoscopy (in addition to a detailed history and physical exam). This not only helps rule out other forms of incontinence, such as overactive bladder, but also evaluates for possible mesh erosion into the urethra or bladder, which can cause irritative voiding symptoms and incontinence.

Continue to: What type of sling did the patient have initially...

What type of sling did the patient have initially, and how does this impact a repeat procedure?

Regardless of the initial sling type used, repeat midurethral sling procedures have a significantly lower cure rate than primary midurethral sling procedures.¹³ Retropubic slings are more effective than transobturator slings for patients with recurrent SUI who have failed a prior sling. When a patient presents with recurrent SUI after a prior transobturator sling, the best option for a repeat procedure is usually a retropubic sling, as it achieves higher objective and subjective cure rates.^13,14 (See FIGURE 2 for a comparison of retropubic and transobturator slings.)


Should I remove the old sling prior to placing a new one?

While it is recommended to remove the vaginal portion of the sling if the patient has a mesh exposure or is experiencing other symptoms, such as pain or bleeding, removal of the old sling is not necessarily indicated prior to (or during) a repeat incontinence procedure.^15,16 Removing the sling, removing a portion of the sling, or leaving the sling in situ are all reasonable options.

CASE 3 Treated SUI has mesh exposure

Ms. R. is a 60-year-old woman with a history of SUI that was previously managed with a retropubic midurethral sling placed at an outside hospital. She is a smoker and has developed a vaginal mesh exposure. Although she would like the mesh removed, she does not want her incontinence to come back. She tells you that she does not think she would be able to quit smoking.

What would be a reasonable next option for Ms. R.?

While complications from a midurethral sling are rare, mesh exposures occur in approximately 2% of patients, and urinary retention requiring release of the sling occurs in about 1% of patients.^3,6 It often helps to clarify for patients that the US Food and Drug Administration public health advisories on the use of transvaginal mesh have been directed specifically toward the use of transvaginal mesh for the treatment of pelvic organ prolapse (POP), not the use of mesh for midurethral slings for SUI or transabdominal mesh for POP.^10,17

When considering use of a mesh sling, a thorough discussion of the potential risks, as well as the benefits and alternatives, is imperative. Patients must personally balance the probability of benefit with the potential risk of complications, and while physicians can help outline the benefits and risks through shared decision-making, ultimately it is the patient who should make this decision.

Certain patient populations may be at higher risk for mesh complications¹⁸ (See "Risk factors for mesh-related complications," below). These complications are managed in various ways (FIGURE 3). Patients who have experienced mesh complications previously are typically not good candidates for a repeat mesh sling, particularly when the risk factor for complications cannot be modified.

A mesh sling alternative

The most effective way to manage SUI in patients who are not good candidates for a mesh sling is to consider employing a sling that uses the patient’s own tissue.^19-21 Common approaches include harvesting a graft of rectus fascia through a Pfannenstiel skin incision or using fascia lata from the patient’s iliotibial band in the lateral thigh. Autologous slings are safe and effective, and even after a mesh sling has failed, autologous slings have an almost 70% cure rate for SUI.^20,21

Continue to: Timing of mesh removal and placement of an autologous fascial sling...

Timing of mesh removal and placement of an autologous fascial sling

Either concomitant or delayed placement of a pubovaginal sling is acceptable when removing mesh, though this should be a joint decision with the patient after counseling. If the risk for surgical complications is modifiable (for example, poorly controlled diabetes that could be improved with blood glucose control), it may be advisable to delay the fascial sling until the risk factors have been addressed. Similarly, if the reason for mesh removal is pain, it may be advisable to remove the mesh prior to placing a new sling to ensure that the pain resolves completely. Otherwise, if pain persists, it can be unclear whether the new sling is contributing to the pain, and this may lead to difficulties treating pain or incontinence in the future.

In this patient, who was an active smoker, we excised the exposed mesh and concomitantly placed an autologous fascial sling utilizing rectus fascia. This maintained continence without introducing mesh in a high-risk patient.

CASE 4 POP and occult SUI

Ms. B. is a 79-year-old woman with stage 3 POP planned for surgical repair. While she does not report urinary leakage, preoperative urodynamic testing revealed occult SUI with reduction of her prolapse. Her priorities are to avoid needing another surgery and to limit the chances of postoperative leakage, but she is nervous about her postoperative recovery and wants to avoid pain.

What approach would be appropriate?

Consider a mini sling for this patient

The single-incision (mini) sling is an option to consider for patients with mild incontinence or for those without evidence of intrinsic sphincter deficiency. It is also a good option for those who want to avoid the additional incisions required for full-length slings.

While currently there is not sufficient evidence to clearly state if single-incision slings are equivalent to other slings, recent studies show that single-incision slings appear to be safe and effective in the short term, with possibly fewer complications than traditional transobturator slings.^22-24 As patients are often concerned about the potential for groin pain with a transobturator sling, a single-incision sling is an acceptable alternative that avoids groin incisions and also avoids the retropubic space.

Patient counseling is crucial

Regardless of the route, sling procedures are highly effective and safe for treating women with SUI.³ Understanding the characteristics of each type of sling and the distinct surgical approaches enables informed counseling for patients who are navigating the treatment options for SUI.

They call themselves dolls. These are cosmetic surgery patients who document their desires and results on Instagram, but only, most say, for other patients or prospective clients. They use names and hashtags that connect the work to their provider. So, for example, KathySmithDoll would be a woman who underwent surgery with a Dr. Kathy Smith.

DragonImages/Getty Images

In an era of patient empowerment, these pages – they’re called “Sx pages,” with Sx mimicking the prescriptive “Rx” – form a just-out-of-sight Instagram community. They serve as a cosmetic surgery shopping guide, a best-practices education system, and can also sound the alarm about bad experiences with practitioners. Some presurgery doll pages are more like inspiration pages or mood boards, collecting images of desired shapes.

That way, “other girls doing research can find someone with a similar build to theirs and follow their journey for a glimpse at what they might look like if they got similar procedures,” said Tai Hall, a massage therapist in Maryland. On her Instagram page, she showcases before-and-after body-contouring results; in her Facebook group, she teaches postoperative self-massage and how people can best take care of themselves while healing.

These Instagram pages, she said, “are really big deals.”

The Sx Instagram pages are private and anonymous, to some extent, and follow strict rules to stay that way, particularly since many feature nudity. (As a social media practice, Sx pages are fairly similar to teenager’s private “finsta” friends-only accounts. They are similarly unverified and what they report is unverifiable.) Many of the bios on these pages indicate they won’t allow access to men.

Each Instagram page bio often unveils elaborate details, often including height and weight. The patient – the doll – will list surgery dates and tag her surgeon, recovery house, any postoperative care specialists or private nurses, and her postoperative massage therapist.

Recovery houses, surgery providers, and massage therapists also use the hashtags to promote their services. Some of these are flooded with ads or spam. Some are used by practitioners for education about surgery.

The surgery age

According to the American Society of Plastic Surgeons, more than 1.8 million cosmetic surgeries were performed in the United States in 2018. Breast augmentation and liposuction accounted for about a third of those.

And the number of “cosmetic minimally invasive procedures” – Botox, laser hair removal, soft-tissue fillers, and more – has grown rapidly in the United States. There were fewer than 5 million procedures in 2000. In 2018, there were nearly 16 million. (Almost half of those procedures are Botox treatments.)

Cosmetic procedures are also becoming more popular among people of color. The American Society for Aesthetic Plastic Surgery reports that cosmetic augmentation, like liposuctions and buttocks lifts, increased 56% among African Americans from 2005 to 2013, and is still rising.

As the number of savvy customers grows, doll pages provide a useful glimpse into the less-glamorous side of before and after – the details that people like to overlook, like bruising, drainage, and the often painfully long process of healing after significant surgeries.

Patients become online advertisements for their surgeons. Surgeons develop a reputation on social media for being the best at certain procedures, for delivering a desired look, or for working with certain ethnic groups and body types.

“They’ll cry and upload videos of pain and success and their struggles, or whatever they’re going through, and their surgery sisters help uplift them,” Ms. Hall said.

And there is a lot to talk about, from surgeons to procedures to recovery houses to advice on how to travel with the least hassle from airport security or airline staff when patients are clad in fajas – a kind of postoperative girdle – or other foam paddings.

How we shop for surgeons now

Sx pages can be an effective patient empowerment tool if done honestly and fairly, said Alan Matarasso, MD, a plastic surgeon in New York and the president of the American Society of Plastic Surgeons.

“It makes sense because this is a small group of people,” he said. “Not a lot of doctors do Brazilian butt lifts, but patients need to realize that they are not rating a restaurant.”

Dr. Matarasso encourages prospective patients who rely on Sx pages to research and prepare in other ways as well.

“The standards have to be even greater than if you had a sick gallbladder, because you don’t have to do this,” he said. “This is not like vetting a hotel room. You have to be careful.”

Dr. Matarasso recommends that prospective patients ask to see the surgeon’s best and worst results, or a random case – say, the 37th case they did that year. He suggests that prospective clients visit the American Board of Plastic Surgery websites to do research and that patients query the licensing state and find out what, if any, violations a surgeon may have had. Patients can ask board-certified surgeons their specialty and whether they are certified in it.

Ms. Hall, the massage therapist, warned that patients may see women who heal faster or achieve different results than they might. As is often the case on Instagram, people tend to post fewer of their struggles and more of their highlight reels.

Patients taking care of patients

Sx pages might be even more valuable for patients who plan to travel internationally for their surgery. Many people in the United States do this to save money. Doll pages serve to warn prospective patients about problems that surgeons and hospitals don’t disclose.

After surgery, especially if extensive travel is needed, patients may recuperate at recovery houses for a few days. Procedures like fat transfer to the buttocks leave patients unable to move around or sit; doctors may install drains to help remove fluid after surgery.

In a recovery house, a caretaker can tend to their incisions; help with bathing, food, and pain medications; and even perform regular postoperative massages.

In May, the mother of an Instagram model named Yatnaa Rivera died during a procedure in the Dominican Republic. Ms. Rivera took to Instagram to ask for help and to warn others. The doctor who performed the operation, Hector Cabral, MD, had been fined for operating in the United States without a license. He is linked to several deaths and is still practicing. (Dr. Cabral did not respond to inquiries via social media; his office answered calls but said he was on vacation.)

Instagram accounts tagged into his doll hashtag (#CabralDoll) to spread the message.

Every day women are bombarded with images of beauty. With filters and editing apps, and the army of social media influencers who receive money or free cosmetic services in exchange for their Instagram posts, it’s often hard to know what’s real. Authentic depictions of what cosmetic surgery entails can be a reality check on what is attainable with cosmetic surgery.

In May 2019, the American College of Surgeons released voluntary ethical guidelines for social media by surgeons. Many of them address patient privacy, but they also advise practitioners to provide trustworthy medical advice and to be cautious around these “powerful educational tools.” Even so, now a real-time, crowdsourced system allows patients to cut through the surgeons’ marketing and advertising efforts.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

They call themselves dolls. These are cosmetic surgery patients who document their desires and results on Instagram, but only, most say, for other patients or prospective clients. They use names and hashtags that connect the work to their provider. So, for example, KathySmithDoll would be a woman who underwent surgery with a Dr. Kathy Smith.

DragonImages/Getty Images

In an era of patient empowerment, these pages – they’re called “Sx pages,” with Sx mimicking the prescriptive “Rx” – form a just-out-of-sight Instagram community. They serve as a cosmetic surgery shopping guide, a best-practices education system, and can also sound the alarm about bad experiences with practitioners. Some presurgery doll pages are more like inspiration pages or mood boards, collecting images of desired shapes.

That way, “other girls doing research can find someone with a similar build to theirs and follow their journey for a glimpse at what they might look like if they got similar procedures,” said Tai Hall, a massage therapist in Maryland. On her Instagram page, she showcases before-and-after body-contouring results; in her Facebook group, she teaches postoperative self-massage and how people can best take care of themselves while healing.

These Instagram pages, she said, “are really big deals.”

The Sx Instagram pages are private and anonymous, to some extent, and follow strict rules to stay that way, particularly since many feature nudity. (As a social media practice, Sx pages are fairly similar to teenager’s private “finsta” friends-only accounts. They are similarly unverified and what they report is unverifiable.) Many of the bios on these pages indicate they won’t allow access to men.

Each Instagram page bio often unveils elaborate details, often including height and weight. The patient – the doll – will list surgery dates and tag her surgeon, recovery house, any postoperative care specialists or private nurses, and her postoperative massage therapist.

Recovery houses, surgery providers, and massage therapists also use the hashtags to promote their services. Some of these are flooded with ads or spam. Some are used by practitioners for education about surgery.

The surgery age

According to the American Society of Plastic Surgeons, more than 1.8 million cosmetic surgeries were performed in the United States in 2018. Breast augmentation and liposuction accounted for about a third of those.

And the number of “cosmetic minimally invasive procedures” – Botox, laser hair removal, soft-tissue fillers, and more – has grown rapidly in the United States. There were fewer than 5 million procedures in 2000. In 2018, there were nearly 16 million. (Almost half of those procedures are Botox treatments.)

Cosmetic procedures are also becoming more popular among people of color. The American Society for Aesthetic Plastic Surgery reports that cosmetic augmentation, like liposuctions and buttocks lifts, increased 56% among African Americans from 2005 to 2013, and is still rising.

As the number of savvy customers grows, doll pages provide a useful glimpse into the less-glamorous side of before and after – the details that people like to overlook, like bruising, drainage, and the often painfully long process of healing after significant surgeries.

Patients become online advertisements for their surgeons. Surgeons develop a reputation on social media for being the best at certain procedures, for delivering a desired look, or for working with certain ethnic groups and body types.

“They’ll cry and upload videos of pain and success and their struggles, or whatever they’re going through, and their surgery sisters help uplift them,” Ms. Hall said.

And there is a lot to talk about, from surgeons to procedures to recovery houses to advice on how to travel with the least hassle from airport security or airline staff when patients are clad in fajas – a kind of postoperative girdle – or other foam paddings.

How we shop for surgeons now

Sx pages can be an effective patient empowerment tool if done honestly and fairly, said Alan Matarasso, MD, a plastic surgeon in New York and the president of the American Society of Plastic Surgeons.

“It makes sense because this is a small group of people,” he said. “Not a lot of doctors do Brazilian butt lifts, but patients need to realize that they are not rating a restaurant.”

Dr. Matarasso encourages prospective patients who rely on Sx pages to research and prepare in other ways as well.

“The standards have to be even greater than if you had a sick gallbladder, because you don’t have to do this,” he said. “This is not like vetting a hotel room. You have to be careful.”

Dr. Matarasso recommends that prospective patients ask to see the surgeon’s best and worst results, or a random case – say, the 37th case they did that year. He suggests that prospective clients visit the American Board of Plastic Surgery websites to do research and that patients query the licensing state and find out what, if any, violations a surgeon may have had. Patients can ask board-certified surgeons their specialty and whether they are certified in it.

Ms. Hall, the massage therapist, warned that patients may see women who heal faster or achieve different results than they might. As is often the case on Instagram, people tend to post fewer of their struggles and more of their highlight reels.

Patients taking care of patients

Sx pages might be even more valuable for patients who plan to travel internationally for their surgery. Many people in the United States do this to save money. Doll pages serve to warn prospective patients about problems that surgeons and hospitals don’t disclose.

After surgery, especially if extensive travel is needed, patients may recuperate at recovery houses for a few days. Procedures like fat transfer to the buttocks leave patients unable to move around or sit; doctors may install drains to help remove fluid after surgery.

In a recovery house, a caretaker can tend to their incisions; help with bathing, food, and pain medications; and even perform regular postoperative massages.

In May, the mother of an Instagram model named Yatnaa Rivera died during a procedure in the Dominican Republic. Ms. Rivera took to Instagram to ask for help and to warn others. The doctor who performed the operation, Hector Cabral, MD, had been fined for operating in the United States without a license. He is linked to several deaths and is still practicing. (Dr. Cabral did not respond to inquiries via social media; his office answered calls but said he was on vacation.)

Instagram accounts tagged into his doll hashtag (#CabralDoll) to spread the message.

Every day women are bombarded with images of beauty. With filters and editing apps, and the army of social media influencers who receive money or free cosmetic services in exchange for their Instagram posts, it’s often hard to know what’s real. Authentic depictions of what cosmetic surgery entails can be a reality check on what is attainable with cosmetic surgery.

In May 2019, the American College of Surgeons released voluntary ethical guidelines for social media by surgeons. Many of them address patient privacy, but they also advise practitioners to provide trustworthy medical advice and to be cautious around these “powerful educational tools.” Even so, now a real-time, crowdsourced system allows patients to cut through the surgeons’ marketing and advertising efforts.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

They call themselves dolls. These are cosmetic surgery patients who document their desires and results on Instagram, but only, most say, for other patients or prospective clients. They use names and hashtags that connect the work to their provider. So, for example, KathySmithDoll would be a woman who underwent surgery with a Dr. Kathy Smith.

DragonImages/Getty Images

In an era of patient empowerment, these pages – they’re called “Sx pages,” with Sx mimicking the prescriptive “Rx” – form a just-out-of-sight Instagram community. They serve as a cosmetic surgery shopping guide, a best-practices education system, and can also sound the alarm about bad experiences with practitioners. Some presurgery doll pages are more like inspiration pages or mood boards, collecting images of desired shapes.

That way, “other girls doing research can find someone with a similar build to theirs and follow their journey for a glimpse at what they might look like if they got similar procedures,” said Tai Hall, a massage therapist in Maryland. On her Instagram page, she showcases before-and-after body-contouring results; in her Facebook group, she teaches postoperative self-massage and how people can best take care of themselves while healing.

These Instagram pages, she said, “are really big deals.”

The Sx Instagram pages are private and anonymous, to some extent, and follow strict rules to stay that way, particularly since many feature nudity. (As a social media practice, Sx pages are fairly similar to teenager’s private “finsta” friends-only accounts. They are similarly unverified and what they report is unverifiable.) Many of the bios on these pages indicate they won’t allow access to men.

Each Instagram page bio often unveils elaborate details, often including height and weight. The patient – the doll – will list surgery dates and tag her surgeon, recovery house, any postoperative care specialists or private nurses, and her postoperative massage therapist.

Recovery houses, surgery providers, and massage therapists also use the hashtags to promote their services. Some of these are flooded with ads or spam. Some are used by practitioners for education about surgery.

The surgery age

According to the American Society of Plastic Surgeons, more than 1.8 million cosmetic surgeries were performed in the United States in 2018. Breast augmentation and liposuction accounted for about a third of those.

And the number of “cosmetic minimally invasive procedures” – Botox, laser hair removal, soft-tissue fillers, and more – has grown rapidly in the United States. There were fewer than 5 million procedures in 2000. In 2018, there were nearly 16 million. (Almost half of those procedures are Botox treatments.)

Cosmetic procedures are also becoming more popular among people of color. The American Society for Aesthetic Plastic Surgery reports that cosmetic augmentation, like liposuctions and buttocks lifts, increased 56% among African Americans from 2005 to 2013, and is still rising.

As the number of savvy customers grows, doll pages provide a useful glimpse into the less-glamorous side of before and after – the details that people like to overlook, like bruising, drainage, and the often painfully long process of healing after significant surgeries.

Patients become online advertisements for their surgeons. Surgeons develop a reputation on social media for being the best at certain procedures, for delivering a desired look, or for working with certain ethnic groups and body types.

“They’ll cry and upload videos of pain and success and their struggles, or whatever they’re going through, and their surgery sisters help uplift them,” Ms. Hall said.

And there is a lot to talk about, from surgeons to procedures to recovery houses to advice on how to travel with the least hassle from airport security or airline staff when patients are clad in fajas – a kind of postoperative girdle – or other foam paddings.

How we shop for surgeons now

Sx pages can be an effective patient empowerment tool if done honestly and fairly, said Alan Matarasso, MD, a plastic surgeon in New York and the president of the American Society of Plastic Surgeons.

“It makes sense because this is a small group of people,” he said. “Not a lot of doctors do Brazilian butt lifts, but patients need to realize that they are not rating a restaurant.”

Dr. Matarasso encourages prospective patients who rely on Sx pages to research and prepare in other ways as well.

“The standards have to be even greater than if you had a sick gallbladder, because you don’t have to do this,” he said. “This is not like vetting a hotel room. You have to be careful.”

Dr. Matarasso recommends that prospective patients ask to see the surgeon’s best and worst results, or a random case – say, the 37th case they did that year. He suggests that prospective clients visit the American Board of Plastic Surgery websites to do research and that patients query the licensing state and find out what, if any, violations a surgeon may have had. Patients can ask board-certified surgeons their specialty and whether they are certified in it.

Ms. Hall, the massage therapist, warned that patients may see women who heal faster or achieve different results than they might. As is often the case on Instagram, people tend to post fewer of their struggles and more of their highlight reels.

Patients taking care of patients

Sx pages might be even more valuable for patients who plan to travel internationally for their surgery. Many people in the United States do this to save money. Doll pages serve to warn prospective patients about problems that surgeons and hospitals don’t disclose.

After surgery, especially if extensive travel is needed, patients may recuperate at recovery houses for a few days. Procedures like fat transfer to the buttocks leave patients unable to move around or sit; doctors may install drains to help remove fluid after surgery.

In a recovery house, a caretaker can tend to their incisions; help with bathing, food, and pain medications; and even perform regular postoperative massages.

In May, the mother of an Instagram model named Yatnaa Rivera died during a procedure in the Dominican Republic. Ms. Rivera took to Instagram to ask for help and to warn others. The doctor who performed the operation, Hector Cabral, MD, had been fined for operating in the United States without a license. He is linked to several deaths and is still practicing. (Dr. Cabral did not respond to inquiries via social media; his office answered calls but said he was on vacation.)

Instagram accounts tagged into his doll hashtag (#CabralDoll) to spread the message.

Every day women are bombarded with images of beauty. With filters and editing apps, and the army of social media influencers who receive money or free cosmetic services in exchange for their Instagram posts, it’s often hard to know what’s real. Authentic depictions of what cosmetic surgery entails can be a reality check on what is attainable with cosmetic surgery.

In May 2019, the American College of Surgeons released voluntary ethical guidelines for social media by surgeons. Many of them address patient privacy, but they also advise practitioners to provide trustworthy medical advice and to be cautious around these “powerful educational tools.” Even so, now a real-time, crowdsourced system allows patients to cut through the surgeons’ marketing and advertising efforts.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

IgG elimination diet combined with probiotics may be beneficial to migraine plus irritable bowel syndrome (IBS), a new study found. Researchers investigated the therapeutic potential of diet based on IgG elimination combined with probiotics on 60 patients with migraine plus IBS. IgG antibodies against 266 food varieties were detected by ELISA. Participants were randomized into 3 groups for treatment of IgG elimination diet or probiotics, or diet combined with probiotics. Among the findings:

• Improvement of migraine and gut symptom was achieved at a certain time point.
• Reduced over the counter (OTC) analgesics was seen in all groups.
• Use of triptans did not show significant difference.
• An increased serum serotonin level was seen in participants treated with elimination diet and elimination diet combined with probiotics.

Xie Y, et al. Effects of diet based on IgG elimination combined with probiotics on migraine plus irritable bowel syndrome. [Published online ahead of print August 21, 2019]. Pain Res Manag. doi: 10.1155/2019/7890461.

IgG elimination diet combined with probiotics may be beneficial to migraine plus irritable bowel syndrome (IBS), a new study found. Researchers investigated the therapeutic potential of diet based on IgG elimination combined with probiotics on 60 patients with migraine plus IBS. IgG antibodies against 266 food varieties were detected by ELISA. Participants were randomized into 3 groups for treatment of IgG elimination diet or probiotics, or diet combined with probiotics. Among the findings:

• Improvement of migraine and gut symptom was achieved at a certain time point.
• Reduced over the counter (OTC) analgesics was seen in all groups.
• Use of triptans did not show significant difference.
• An increased serum serotonin level was seen in participants treated with elimination diet and elimination diet combined with probiotics.

Xie Y, et al. Effects of diet based on IgG elimination combined with probiotics on migraine plus irritable bowel syndrome. [Published online ahead of print August 21, 2019]. Pain Res Manag. doi: 10.1155/2019/7890461.

IgG elimination diet combined with probiotics may be beneficial to migraine plus irritable bowel syndrome (IBS), a new study found. Researchers investigated the therapeutic potential of diet based on IgG elimination combined with probiotics on 60 patients with migraine plus IBS. IgG antibodies against 266 food varieties were detected by ELISA. Participants were randomized into 3 groups for treatment of IgG elimination diet or probiotics, or diet combined with probiotics. Among the findings:

• Improvement of migraine and gut symptom was achieved at a certain time point.
• Reduced over the counter (OTC) analgesics was seen in all groups.
• Use of triptans did not show significant difference.
• An increased serum serotonin level was seen in participants treated with elimination diet and elimination diet combined with probiotics.

Xie Y, et al. Effects of diet based on IgG elimination combined with probiotics on migraine plus irritable bowel syndrome. [Published online ahead of print August 21, 2019]. Pain Res Manag. doi: 10.1155/2019/7890461.

Excitatory non-invasive brain stimulation (NIBS) of the excitatory primary motor cortex (M1) is likely to reduce headache intensity and the frequency of headache attacks in patients with migraine, a new study found. Researchers quantitatively reviewed the efficacy of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) in randomized controlled trials (RTCs) in modifying headache intensity and frequency of headache attacks in patients with migraine. A random meta-analysis was performed to pool effect sizes of outcomes. Among the findings:

• Nine RCTs with 276 participants were included.
• Meta-analysis of excitatory M1 stimulation demonstrated significant effects on reducing headache intensity in patients with migraine.
• Meta-analysis of excitatory M1 stimulation showed significant effects on reducing frequency of headache attacks in patients with migraine.

Feng Y, et al. Effects of non-invasive brain stimulation on headache intensity and frequency of headache attacks in patients with migraine: A systematic review and meta-analysis. [Published online ahead of print September 18, 2019]. Headache. doi: 10.1111/head.13645.

Excitatory non-invasive brain stimulation (NIBS) of the excitatory primary motor cortex (M1) is likely to reduce headache intensity and the frequency of headache attacks in patients with migraine, a new study found. Researchers quantitatively reviewed the efficacy of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) in randomized controlled trials (RTCs) in modifying headache intensity and frequency of headache attacks in patients with migraine. A random meta-analysis was performed to pool effect sizes of outcomes. Among the findings:

• Nine RCTs with 276 participants were included.
• Meta-analysis of excitatory M1 stimulation demonstrated significant effects on reducing headache intensity in patients with migraine.
• Meta-analysis of excitatory M1 stimulation showed significant effects on reducing frequency of headache attacks in patients with migraine.

Feng Y, et al. Effects of non-invasive brain stimulation on headache intensity and frequency of headache attacks in patients with migraine: A systematic review and meta-analysis. [Published online ahead of print September 18, 2019]. Headache. doi: 10.1111/head.13645.

Excitatory non-invasive brain stimulation (NIBS) of the excitatory primary motor cortex (M1) is likely to reduce headache intensity and the frequency of headache attacks in patients with migraine, a new study found. Researchers quantitatively reviewed the efficacy of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) in randomized controlled trials (RTCs) in modifying headache intensity and frequency of headache attacks in patients with migraine. A random meta-analysis was performed to pool effect sizes of outcomes. Among the findings:

• Nine RCTs with 276 participants were included.
• Meta-analysis of excitatory M1 stimulation demonstrated significant effects on reducing headache intensity in patients with migraine.
• Meta-analysis of excitatory M1 stimulation showed significant effects on reducing frequency of headache attacks in patients with migraine.

Feng Y, et al. Effects of non-invasive brain stimulation on headache intensity and frequency of headache attacks in patients with migraine: A systematic review and meta-analysis. [Published online ahead of print September 18, 2019]. Headache. doi: 10.1111/head.13645.

Osmophobia is a specific clinical marker of migraine, but not tension-type headache, a new study found. Researchers conducted a prospective study on 193 patients suffering from migraine without aura, migraine with aura, episodic tension-type headache, or a combination of these. Each patient was asked to describe in detail osmophobia, when present, in the 4 headache attacks. Among the findings:

• 45.7% of migraine with aura attacks were associated with osmophobia.
• 67.2% of patients with migraine reported osmophobia in at least a quarter of the attacks.
• No tension-type headache attack was associated with osmophobia.

Terrin A, et al. A prospective study on osmophobia in migraine versus tension-type headache in a large series of attacks. [Published online ahead of print September 19, 2019]. Cephalalgia. doi: 10.1177/0333102419877661.

Osmophobia is a specific clinical marker of migraine, but not tension-type headache, a new study found. Researchers conducted a prospective study on 193 patients suffering from migraine without aura, migraine with aura, episodic tension-type headache, or a combination of these. Each patient was asked to describe in detail osmophobia, when present, in the 4 headache attacks. Among the findings:

• 45.7% of migraine with aura attacks were associated with osmophobia.
• 67.2% of patients with migraine reported osmophobia in at least a quarter of the attacks.
• No tension-type headache attack was associated with osmophobia.

Terrin A, et al. A prospective study on osmophobia in migraine versus tension-type headache in a large series of attacks. [Published online ahead of print September 19, 2019]. Cephalalgia. doi: 10.1177/0333102419877661.

Osmophobia is a specific clinical marker of migraine, but not tension-type headache, a new study found. Researchers conducted a prospective study on 193 patients suffering from migraine without aura, migraine with aura, episodic tension-type headache, or a combination of these. Each patient was asked to describe in detail osmophobia, when present, in the 4 headache attacks. Among the findings:

• 45.7% of migraine with aura attacks were associated with osmophobia.
• 67.2% of patients with migraine reported osmophobia in at least a quarter of the attacks.
• No tension-type headache attack was associated with osmophobia.

Terrin A, et al. A prospective study on osmophobia in migraine versus tension-type headache in a large series of attacks. [Published online ahead of print September 19, 2019]. Cephalalgia. doi: 10.1177/0333102419877661.

When first responders arrive at a scene where illicit drugs may be present, they could be at risk of dangerous exposure. They might inhale drugs; they can have contact through mucous membranes or through needlesticks.

A major concern is exposure to fentanyl or its analogues, which can lead to symptoms, including rapid onset of life-threatening respiratory depression. The exception is skin contact, which is not expected to have toxic effects if the visible contamination is removed promptly.

To help EMS providers and other responders protect themselves, the National Institute for Occupational Safety and Health (NIOSH) has released a new virtual toolkit with videos, infographics, and postcards based on NIOSH safety recommendations.

The resources highlight how best to assess the scene for hazards that may indicate the presence of illicit drugs and what to do—for example, use soap and water, not hand sanitizer (it doesn’t remove illicit drugs and may increase exposure), and don’t eat, drink, smoke, or use the bathroom in the affected area. The infographics also show how to decontaminate and prevent “take-home exposure” to protect responders’ families. The guidelines extend to procedures for protecting working dogs exposed to the drugs.

NIOSH notes that it has no occupational exposure data on fentanyl or its analogues for emergency responders. The recommendations are based on the reported toxicity and the chemical and physical properties of fentanyl and its analogues, NIOSH guidance for similar chemicals, recommendations from previous NIOSH health hazard evaluation reports, and “the basic principles of industrial hygiene.” As new research becomes available, NIOSH says, the recommendations will be updated.

The toolkit resources are shareable and available for disseminating via print, social media, text, and more. The kit is accessible at https://www.cdc.gov/niosh/topics/fentanyl/toolkit.html.

When first responders arrive at a scene where illicit drugs may be present, they could be at risk of dangerous exposure. They might inhale drugs; they can have contact through mucous membranes or through needlesticks.

A major concern is exposure to fentanyl or its analogues, which can lead to symptoms, including rapid onset of life-threatening respiratory depression. The exception is skin contact, which is not expected to have toxic effects if the visible contamination is removed promptly.

To help EMS providers and other responders protect themselves, the National Institute for Occupational Safety and Health (NIOSH) has released a new virtual toolkit with videos, infographics, and postcards based on NIOSH safety recommendations.

The resources highlight how best to assess the scene for hazards that may indicate the presence of illicit drugs and what to do—for example, use soap and water, not hand sanitizer (it doesn’t remove illicit drugs and may increase exposure), and don’t eat, drink, smoke, or use the bathroom in the affected area. The infographics also show how to decontaminate and prevent “take-home exposure” to protect responders’ families. The guidelines extend to procedures for protecting working dogs exposed to the drugs.

NIOSH notes that it has no occupational exposure data on fentanyl or its analogues for emergency responders. The recommendations are based on the reported toxicity and the chemical and physical properties of fentanyl and its analogues, NIOSH guidance for similar chemicals, recommendations from previous NIOSH health hazard evaluation reports, and “the basic principles of industrial hygiene.” As new research becomes available, NIOSH says, the recommendations will be updated.

The toolkit resources are shareable and available for disseminating via print, social media, text, and more. The kit is accessible at https://www.cdc.gov/niosh/topics/fentanyl/toolkit.html.

When first responders arrive at a scene where illicit drugs may be present, they could be at risk of dangerous exposure. They might inhale drugs; they can have contact through mucous membranes or through needlesticks.

A major concern is exposure to fentanyl or its analogues, which can lead to symptoms, including rapid onset of life-threatening respiratory depression. The exception is skin contact, which is not expected to have toxic effects if the visible contamination is removed promptly.

To help EMS providers and other responders protect themselves, the National Institute for Occupational Safety and Health (NIOSH) has released a new virtual toolkit with videos, infographics, and postcards based on NIOSH safety recommendations.

The resources highlight how best to assess the scene for hazards that may indicate the presence of illicit drugs and what to do—for example, use soap and water, not hand sanitizer (it doesn’t remove illicit drugs and may increase exposure), and don’t eat, drink, smoke, or use the bathroom in the affected area. The infographics also show how to decontaminate and prevent “take-home exposure” to protect responders’ families. The guidelines extend to procedures for protecting working dogs exposed to the drugs.

NIOSH notes that it has no occupational exposure data on fentanyl or its analogues for emergency responders. The recommendations are based on the reported toxicity and the chemical and physical properties of fentanyl and its analogues, NIOSH guidance for similar chemicals, recommendations from previous NIOSH health hazard evaluation reports, and “the basic principles of industrial hygiene.” As new research becomes available, NIOSH says, the recommendations will be updated.

The toolkit resources are shareable and available for disseminating via print, social media, text, and more. The kit is accessible at https://www.cdc.gov/niosh/topics/fentanyl/toolkit.html.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.

Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.

Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.

Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.

Background: Sepsis is responsible for an increasingly disproportionate fraction of health care burden. Delays in diagnosis of sepsis are associated with worse outcomes.

Dr. Ho is an assistant professor of medicine in the division of general and hospital medicine at UT Health San Antonio and a hospitalist at South Texas Veterans Health Care System.

Relatively few of the adverse health outcomes attributed to antidepressants are supported by convincing evidence, reported the authors of a systematic review of 45 meta-analyses.

The authors did find convincing evidence linking the use of antidepressants and suicide attempt or completion among people under age 19 years and use of the medication and autism risk among offspring. “However, the few [studies] with convincing evidence associations did not reflect causality, and none of them remained at the convincing evidence level after accounting for confounding by indication,” wrote Elena Dragioti, PhD, of the Pain and Rehabilitation Centre at Linköping (Sweden) University and coauthors. The study was published in JAMA Psychiatry.

Dr. Dragioti and coauthors undertook a systematic “umbrella review” grading the evidence from the 45 meta-analyses of 695 observational studies into the association between antidepressant use and the risk of adverse health outcomes. All the meta-analyses included a control group not exposed to antidepressants, with the exception of one that compared the risk of gastrointestinal bleeding between two classes of antidepressants.

They found 120 possible adverse health associations described in the meta-analyses, 61.7% of which related to maternal and pregnancy-related adverse health outcomes. Two-thirds of the adverse health outcome associations involved selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

However, among the 120 adverse health associations, only three (2.5%) were supported by “convincing” evidence. One was the association between SSRIs and increased risk of suicide attempts and completion in children and adolescents. Convincing evidence also was found between any antidepressant use before pregnancy and autism spectrum disorder and between SSRI use during pregnancy and autism spectrum disorder. The evidence for the association with suicide risk was deemed high quality, but the two associations with autism spectrum disorder were only of moderate quality.

The authors commented that these findings needed to be considered when prescribing antidepressants in adolescents and children, particularly as another networked meta-analysis had found fluoxetine was the only antidepressant that worked better than placebo in children and adolescents. “In addition, the increased suicidality in children and adolescents who use antidepressants may be associated with the unsuccessful reduction of depressive symptoms in suicidal individuals rather than a direct result of antidepressant use,” they wrote.

The review found that 11 adverse health outcomes (9.2%) had “highly suggestive” evidence linking them to antidepressant use. These were ADHD in children, cataract development, severe bleeding at any site, upper gastrointestinal tract bleeding, postpartum hemorrhage, preterm birth, lower Apgar score at 5 minutes, osteoporotic fracture, and hip fracture.

Seven of those – ADHD in children, lower Apgar score, severe bleeding at any site, cataract development, osteoporotic features, preterm birth, and upper GI bleeding – had moderate-quality evidence. However, the authors noted that the effect sizes were small and had low prevalence.

The study also found highly suggestive evidence linking antidepressant use to a decreased risk of suicide attempts or completion in adults.

The authors said several of those adverse events in adults, such as GI bleeding and osteoporotic fractures, could be prevented with medication, so the advantages of antidepressant use in adults could outweigh the disadvantage of those preventable safety issues.

Twenty-one adverse health outcomes showed either suggestive, weak, or no evidence for their association with antidepressant use.

They also conducted a sensitivity analysis that limited the analysis to cohort studies, prospective cohort studies, studies that controlled for confounding by the treatment indication, and studies from North America. This showed that none of the associations for which there was originally deemed to be convincing evidence retained that same rank.

“Overall, the results showed that the association between antidepressant use and adverse health outcomes was not supported by robust evidence and that the underlying disease likely inflated the findings in a relevant way,” the authors wrote.

However, when they looked solely at prospective cohort studies, the association between preterm birth and use of any antidepressant was upgraded to having convincing evidence.

When the analysis focused on SSRIs only, the association with lower Apgar scores at 5 minutes also was upgraded to having convincing evidence. Similarly, the evidence for an association with preterm birth also was found to be convincing when the analysis was limited to other or mixed antidepressants.

Dr. Dragioti and coauthors cited several limitations, including the inability of some randomized, controlled trials to address adverse outcomes.

“Antidepressant use appears to be safe for the treatment of psychiatric disorders, but more studies matching for underlying disease are needed to clarify the degree of confounding by indication and other biases,” the authors wrote.

The study was funded by several entities, including the National Institute for Health Research’s Biomedical Research Centre at South London and Maudsley NHS Foundation Trust. Dr. Dragioti reported no disclosures. Four authors declared funding, consultancies, personal fees, royalties, or shares in the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Dragioti E et al. JAMA Psychiatry. 2019 Oct 2. doi: 10.1001/jamapsychiatry.2019.2859.

Relatively few of the adverse health outcomes attributed to antidepressants are supported by convincing evidence, reported the authors of a systematic review of 45 meta-analyses.

The authors did find convincing evidence linking the use of antidepressants and suicide attempt or completion among people under age 19 years and use of the medication and autism risk among offspring. “However, the few [studies] with convincing evidence associations did not reflect causality, and none of them remained at the convincing evidence level after accounting for confounding by indication,” wrote Elena Dragioti, PhD, of the Pain and Rehabilitation Centre at Linköping (Sweden) University and coauthors. The study was published in JAMA Psychiatry.

Dr. Dragioti and coauthors undertook a systematic “umbrella review” grading the evidence from the 45 meta-analyses of 695 observational studies into the association between antidepressant use and the risk of adverse health outcomes. All the meta-analyses included a control group not exposed to antidepressants, with the exception of one that compared the risk of gastrointestinal bleeding between two classes of antidepressants.

They found 120 possible adverse health associations described in the meta-analyses, 61.7% of which related to maternal and pregnancy-related adverse health outcomes. Two-thirds of the adverse health outcome associations involved selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

However, among the 120 adverse health associations, only three (2.5%) were supported by “convincing” evidence. One was the association between SSRIs and increased risk of suicide attempts and completion in children and adolescents. Convincing evidence also was found between any antidepressant use before pregnancy and autism spectrum disorder and between SSRI use during pregnancy and autism spectrum disorder. The evidence for the association with suicide risk was deemed high quality, but the two associations with autism spectrum disorder were only of moderate quality.

The authors commented that these findings needed to be considered when prescribing antidepressants in adolescents and children, particularly as another networked meta-analysis had found fluoxetine was the only antidepressant that worked better than placebo in children and adolescents. “In addition, the increased suicidality in children and adolescents who use antidepressants may be associated with the unsuccessful reduction of depressive symptoms in suicidal individuals rather than a direct result of antidepressant use,” they wrote.

The review found that 11 adverse health outcomes (9.2%) had “highly suggestive” evidence linking them to antidepressant use. These were ADHD in children, cataract development, severe bleeding at any site, upper gastrointestinal tract bleeding, postpartum hemorrhage, preterm birth, lower Apgar score at 5 minutes, osteoporotic fracture, and hip fracture.

Seven of those – ADHD in children, lower Apgar score, severe bleeding at any site, cataract development, osteoporotic features, preterm birth, and upper GI bleeding – had moderate-quality evidence. However, the authors noted that the effect sizes were small and had low prevalence.

The study also found highly suggestive evidence linking antidepressant use to a decreased risk of suicide attempts or completion in adults.

The authors said several of those adverse events in adults, such as GI bleeding and osteoporotic fractures, could be prevented with medication, so the advantages of antidepressant use in adults could outweigh the disadvantage of those preventable safety issues.

Twenty-one adverse health outcomes showed either suggestive, weak, or no evidence for their association with antidepressant use.

They also conducted a sensitivity analysis that limited the analysis to cohort studies, prospective cohort studies, studies that controlled for confounding by the treatment indication, and studies from North America. This showed that none of the associations for which there was originally deemed to be convincing evidence retained that same rank.

“Overall, the results showed that the association between antidepressant use and adverse health outcomes was not supported by robust evidence and that the underlying disease likely inflated the findings in a relevant way,” the authors wrote.

However, when they looked solely at prospective cohort studies, the association between preterm birth and use of any antidepressant was upgraded to having convincing evidence.

When the analysis focused on SSRIs only, the association with lower Apgar scores at 5 minutes also was upgraded to having convincing evidence. Similarly, the evidence for an association with preterm birth also was found to be convincing when the analysis was limited to other or mixed antidepressants.

Dr. Dragioti and coauthors cited several limitations, including the inability of some randomized, controlled trials to address adverse outcomes.

“Antidepressant use appears to be safe for the treatment of psychiatric disorders, but more studies matching for underlying disease are needed to clarify the degree of confounding by indication and other biases,” the authors wrote.

The study was funded by several entities, including the National Institute for Health Research’s Biomedical Research Centre at South London and Maudsley NHS Foundation Trust. Dr. Dragioti reported no disclosures. Four authors declared funding, consultancies, personal fees, royalties, or shares in the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Dragioti E et al. JAMA Psychiatry. 2019 Oct 2. doi: 10.1001/jamapsychiatry.2019.2859.

Relatively few of the adverse health outcomes attributed to antidepressants are supported by convincing evidence, reported the authors of a systematic review of 45 meta-analyses.

The authors did find convincing evidence linking the use of antidepressants and suicide attempt or completion among people under age 19 years and use of the medication and autism risk among offspring. “However, the few [studies] with convincing evidence associations did not reflect causality, and none of them remained at the convincing evidence level after accounting for confounding by indication,” wrote Elena Dragioti, PhD, of the Pain and Rehabilitation Centre at Linköping (Sweden) University and coauthors. The study was published in JAMA Psychiatry.

Dr. Dragioti and coauthors undertook a systematic “umbrella review” grading the evidence from the 45 meta-analyses of 695 observational studies into the association between antidepressant use and the risk of adverse health outcomes. All the meta-analyses included a control group not exposed to antidepressants, with the exception of one that compared the risk of gastrointestinal bleeding between two classes of antidepressants.

They found 120 possible adverse health associations described in the meta-analyses, 61.7% of which related to maternal and pregnancy-related adverse health outcomes. Two-thirds of the adverse health outcome associations involved selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

However, among the 120 adverse health associations, only three (2.5%) were supported by “convincing” evidence. One was the association between SSRIs and increased risk of suicide attempts and completion in children and adolescents. Convincing evidence also was found between any antidepressant use before pregnancy and autism spectrum disorder and between SSRI use during pregnancy and autism spectrum disorder. The evidence for the association with suicide risk was deemed high quality, but the two associations with autism spectrum disorder were only of moderate quality.

The authors commented that these findings needed to be considered when prescribing antidepressants in adolescents and children, particularly as another networked meta-analysis had found fluoxetine was the only antidepressant that worked better than placebo in children and adolescents. “In addition, the increased suicidality in children and adolescents who use antidepressants may be associated with the unsuccessful reduction of depressive symptoms in suicidal individuals rather than a direct result of antidepressant use,” they wrote.

The review found that 11 adverse health outcomes (9.2%) had “highly suggestive” evidence linking them to antidepressant use. These were ADHD in children, cataract development, severe bleeding at any site, upper gastrointestinal tract bleeding, postpartum hemorrhage, preterm birth, lower Apgar score at 5 minutes, osteoporotic fracture, and hip fracture.

Seven of those – ADHD in children, lower Apgar score, severe bleeding at any site, cataract development, osteoporotic features, preterm birth, and upper GI bleeding – had moderate-quality evidence. However, the authors noted that the effect sizes were small and had low prevalence.

The study also found highly suggestive evidence linking antidepressant use to a decreased risk of suicide attempts or completion in adults.

The authors said several of those adverse events in adults, such as GI bleeding and osteoporotic fractures, could be prevented with medication, so the advantages of antidepressant use in adults could outweigh the disadvantage of those preventable safety issues.

Twenty-one adverse health outcomes showed either suggestive, weak, or no evidence for their association with antidepressant use.

They also conducted a sensitivity analysis that limited the analysis to cohort studies, prospective cohort studies, studies that controlled for confounding by the treatment indication, and studies from North America. This showed that none of the associations for which there was originally deemed to be convincing evidence retained that same rank.

“Overall, the results showed that the association between antidepressant use and adverse health outcomes was not supported by robust evidence and that the underlying disease likely inflated the findings in a relevant way,” the authors wrote.

However, when they looked solely at prospective cohort studies, the association between preterm birth and use of any antidepressant was upgraded to having convincing evidence.

When the analysis focused on SSRIs only, the association with lower Apgar scores at 5 minutes also was upgraded to having convincing evidence. Similarly, the evidence for an association with preterm birth also was found to be convincing when the analysis was limited to other or mixed antidepressants.

Dr. Dragioti and coauthors cited several limitations, including the inability of some randomized, controlled trials to address adverse outcomes.

“Antidepressant use appears to be safe for the treatment of psychiatric disorders, but more studies matching for underlying disease are needed to clarify the degree of confounding by indication and other biases,” the authors wrote.

The study was funded by several entities, including the National Institute for Health Research’s Biomedical Research Centre at South London and Maudsley NHS Foundation Trust. Dr. Dragioti reported no disclosures. Four authors declared funding, consultancies, personal fees, royalties, or shares in the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Dragioti E et al. JAMA Psychiatry. 2019 Oct 2. doi: 10.1001/jamapsychiatry.2019.2859.

Teenage girls with ADHD may be at greater risk of pregnancy than their unaffected peers, which suggests they may benefit from targeted interventions to prevent teen pregnancy.

Rawpixel/Thinkstock

A Swedish nationwide cohort study published in JAMA Network Open examined data from 384,103 nulliparous women and girls who gave birth between 2007-2014, of whom, 6,410 (1.7%) had received treatment for ADHD.

While the overall rate of teenage births was 3%, the rate among women and girls with ADHD was 15.3%, which represents a greater than sixfold higher odds of giving birth below the age of 20 years (odds ratio, 6.23; 95% confidence interval, 5.80-6.68).

“Becoming a mother at such early age is associated with long-term adverse outcomes for both women and their children,” wrote Charlotte Skoglund, PhD, of the department of clinical neuroscience at the Karolinska Institute in Stockholm and coauthors. “Consequently, our findings argue for an improvement in the standard of care for women and girls with ADHD, including active efforts to prevent teenage pregnancies and address comorbid medical and psychiatric conditions.”

The study also found women and girls with ADHD were significantly more likely to be underweight (OR, 1.29; 95% CI, 1.12-1.49) or have a body mass index greater than 40 kg/m² (OR, 2.01; 95% CI, 1.60-2.52) when compared with those without ADHD.

They were also six times more likely to smoke, were nearly seven times more likely to continue smoking into their third trimester of pregnancy, and had a 20-fold higher odds of alcohol and substance use disorder. Among individuals who had been diagnosed with ADHD, 7.6% continued to use stimulant and nonstimulant ADHD medication during pregnancy, and 16.4% used antidepressants during pregnancy.

Psychiatric comorbidities were also significantly more common among individuals with ADHD in the year preceding pregnancy, compared with those without ADHD. The authors saw a 17-fold higher odds of receiving a diagnosis of bipolar disorder, nearly 8-fold higher odds of a diagnosis of schizophrenia or other psychotic disorder, and 22-fold higher odds of being diagnosed with emotionally unstable personality disorder among women and girls with ADHD versus those without.

The authors commented that antenatal care should focus on trying to reduce such obstetric risk factors in these women, but also pointed out that ADHD in women and girls was still underdiagnosed and undertreated.

Commenting on the association between ADHD and teenage pregnancy, the authors noted that women and girls with ADHD may be less likely to receive adequate contraceptive counseling and less likely to access, respond to, and act on counseling. They may also experience more adverse effects from hormonal contraceptives.

While Swedish youth clinics enable easier and low-cost access to counseling and contraception, the authors called for greater collaboration between psychiatric care clinics and specialized youth clinics to provide adequate care for women and girls with ADHD.

Three authors declared advisory board positions, grants, personal fees, and speakers’ fees from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Skoglund C et al. JAMA Netw Open. 2019 Oct 2. doi: 10.1001/jamanetworkopen.2019.12463

Teenage girls with ADHD may be at greater risk of pregnancy than their unaffected peers, which suggests they may benefit from targeted interventions to prevent teen pregnancy.

Rawpixel/Thinkstock

A Swedish nationwide cohort study published in JAMA Network Open examined data from 384,103 nulliparous women and girls who gave birth between 2007-2014, of whom, 6,410 (1.7%) had received treatment for ADHD.

While the overall rate of teenage births was 3%, the rate among women and girls with ADHD was 15.3%, which represents a greater than sixfold higher odds of giving birth below the age of 20 years (odds ratio, 6.23; 95% confidence interval, 5.80-6.68).

“Becoming a mother at such early age is associated with long-term adverse outcomes for both women and their children,” wrote Charlotte Skoglund, PhD, of the department of clinical neuroscience at the Karolinska Institute in Stockholm and coauthors. “Consequently, our findings argue for an improvement in the standard of care for women and girls with ADHD, including active efforts to prevent teenage pregnancies and address comorbid medical and psychiatric conditions.”

The study also found women and girls with ADHD were significantly more likely to be underweight (OR, 1.29; 95% CI, 1.12-1.49) or have a body mass index greater than 40 kg/m² (OR, 2.01; 95% CI, 1.60-2.52) when compared with those without ADHD.

They were also six times more likely to smoke, were nearly seven times more likely to continue smoking into their third trimester of pregnancy, and had a 20-fold higher odds of alcohol and substance use disorder. Among individuals who had been diagnosed with ADHD, 7.6% continued to use stimulant and nonstimulant ADHD medication during pregnancy, and 16.4% used antidepressants during pregnancy.

Psychiatric comorbidities were also significantly more common among individuals with ADHD in the year preceding pregnancy, compared with those without ADHD. The authors saw a 17-fold higher odds of receiving a diagnosis of bipolar disorder, nearly 8-fold higher odds of a diagnosis of schizophrenia or other psychotic disorder, and 22-fold higher odds of being diagnosed with emotionally unstable personality disorder among women and girls with ADHD versus those without.

The authors commented that antenatal care should focus on trying to reduce such obstetric risk factors in these women, but also pointed out that ADHD in women and girls was still underdiagnosed and undertreated.

Commenting on the association between ADHD and teenage pregnancy, the authors noted that women and girls with ADHD may be less likely to receive adequate contraceptive counseling and less likely to access, respond to, and act on counseling. They may also experience more adverse effects from hormonal contraceptives.

While Swedish youth clinics enable easier and low-cost access to counseling and contraception, the authors called for greater collaboration between psychiatric care clinics and specialized youth clinics to provide adequate care for women and girls with ADHD.

Three authors declared advisory board positions, grants, personal fees, and speakers’ fees from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Skoglund C et al. JAMA Netw Open. 2019 Oct 2. doi: 10.1001/jamanetworkopen.2019.12463

Teenage girls with ADHD may be at greater risk of pregnancy than their unaffected peers, which suggests they may benefit from targeted interventions to prevent teen pregnancy.

Rawpixel/Thinkstock

A Swedish nationwide cohort study published in JAMA Network Open examined data from 384,103 nulliparous women and girls who gave birth between 2007-2014, of whom, 6,410 (1.7%) had received treatment for ADHD.

While the overall rate of teenage births was 3%, the rate among women and girls with ADHD was 15.3%, which represents a greater than sixfold higher odds of giving birth below the age of 20 years (odds ratio, 6.23; 95% confidence interval, 5.80-6.68).

“Becoming a mother at such early age is associated with long-term adverse outcomes for both women and their children,” wrote Charlotte Skoglund, PhD, of the department of clinical neuroscience at the Karolinska Institute in Stockholm and coauthors. “Consequently, our findings argue for an improvement in the standard of care for women and girls with ADHD, including active efforts to prevent teenage pregnancies and address comorbid medical and psychiatric conditions.”

The study also found women and girls with ADHD were significantly more likely to be underweight (OR, 1.29; 95% CI, 1.12-1.49) or have a body mass index greater than 40 kg/m² (OR, 2.01; 95% CI, 1.60-2.52) when compared with those without ADHD.

They were also six times more likely to smoke, were nearly seven times more likely to continue smoking into their third trimester of pregnancy, and had a 20-fold higher odds of alcohol and substance use disorder. Among individuals who had been diagnosed with ADHD, 7.6% continued to use stimulant and nonstimulant ADHD medication during pregnancy, and 16.4% used antidepressants during pregnancy.

Psychiatric comorbidities were also significantly more common among individuals with ADHD in the year preceding pregnancy, compared with those without ADHD. The authors saw a 17-fold higher odds of receiving a diagnosis of bipolar disorder, nearly 8-fold higher odds of a diagnosis of schizophrenia or other psychotic disorder, and 22-fold higher odds of being diagnosed with emotionally unstable personality disorder among women and girls with ADHD versus those without.

The authors commented that antenatal care should focus on trying to reduce such obstetric risk factors in these women, but also pointed out that ADHD in women and girls was still underdiagnosed and undertreated.

Commenting on the association between ADHD and teenage pregnancy, the authors noted that women and girls with ADHD may be less likely to receive adequate contraceptive counseling and less likely to access, respond to, and act on counseling. They may also experience more adverse effects from hormonal contraceptives.

While Swedish youth clinics enable easier and low-cost access to counseling and contraception, the authors called for greater collaboration between psychiatric care clinics and specialized youth clinics to provide adequate care for women and girls with ADHD.

Three authors declared advisory board positions, grants, personal fees, and speakers’ fees from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Skoglund C et al. JAMA Netw Open. 2019 Oct 2. doi: 10.1001/jamanetworkopen.2019.12463